Management of an External Iliac Artery Aneurysm
Identifieur interne : 006852 ( Istex/Corpus ); précédent : 006851; suivant : 006853Management of an External Iliac Artery Aneurysm
Auteurs : Eric S. Weinstein ; Kenneth E. Mcintyre ; Wesley S. Moore ; Cornelius OlcottSource :
- Perspectives in Vascular Surgery and Endovascular Therapy [ 1531-0035 ] ; 1994-03.
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DOI: 10.1177/153100359400700106
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<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Weinstein</surname><given-names>Eric S.</given-names></name><degrees>M.D.</degrees></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>McIntyre</surname><given-names>Kenneth E.</given-names><suffix>Jr.</suffix></name><degrees>M.D.</degrees></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Moore</surname><given-names>Wesley S.</given-names></name><degrees>M.D.</degrees></contrib></contrib-group>
<contrib-group><contrib contrib-type="author" xlink:type="simple"><name name-style="western"><surname>Olcott</surname><given-names>Cornelius</given-names><suffix>IV</suffix></name><degrees>M.D.</degrees></contrib></contrib-group>
<pub-date pub-type="ppub"><month>3</month><year>1994</year></pub-date><volume>7</volume><issue>1</issue><fpage>35</fpage><lpage>45</lpage><custom-meta-wrap><custom-meta xlink:type="simple"><meta-name>sagemeta-type</meta-name><meta-value>Journal Article</meta-value></custom-meta><custom-meta xlink:type="simple"><meta-name>search-text</meta-name><meta-value>35 Management of an External Iliac Artery Aneurysm SAGE Publications, Inc.1994DOI: 10.1177/153100359400700106 Eric S. Weinstein M.D. Kenneth E.McIntyre Jr.M.D. Wesley S. Moore M.D. Cornelius IVOlcottM.D. Moderator: A 71-year-old vvhite man was admitted to the medical service with a 5-day history of left lower extremity edema and cellulitis. The patient had been hospitalized 2 months before for a right lower extremity cellulitis and Staphylococcus aureus bacteremia. His medical history was significant for gout, chronic renal insufficiency, and intermittent atrial fibrillation. Seventeen years ago he had an abdominoperineal resection for cancer and 9 months ago he had colostomy revision for parastomal hernia repair. Physical examination revealed an obese man in mild respiratory distress. His temperature was 36.5° C, his blood pressure was 146/82 mm Hg, his heart rate was 108 beats per minute with irregular rhythm, and his respirations were 20 beats per minute. His lungs were noted to be clear. Cardiac examination revealed the irregular rhythm and no murmur. There were well-healed incisions on his abdomen and a functioning colostomy in the left upper quadrant. An extremity examination revealed 2 + edema to the midthigh on the left with erythema extending to the knee. His right leg had no swelling. Arterial examination revealed palpable pedal pulses on the right and biphasic Doppler signals on the left. Admission laboratory values included room air arterial blood gas pH of 7.46, pC02 of 34 mm Hg, p02 of 48 mm Hg, Hco3 of 23.8 mm Hg, and saturation of 82.7%, with an A-a gradient of 34.5. The hematocrit level was 37.5%, white blood cell count was 6.3 x 109/L, blood urea nitrogen was 22 mg/dl, and creatinine level was 2 mg/dl. Lower extremity venous duplex scanning revealed extensive thrombosis of the deep veins of the left leg, extending from the iliac to the tibial veins. The patient was given heparin and a cephalosporin antibiotic. Two of four blood cultures were positive for S. epidermidis so vancomycin was prescribed. A transesophageal echocardiogram ruled out any cardiac vegetations. On the fourth hospital day a surgical consultation eliminated the possibility of a septic deep venous thrombosis. Subsequent to that, a computed tomography (CT) scan of the abdomen and pelvis ruled out a recurrent cancer as the cause of extrinsic compression of the vein and deep vein thrombosis (Fig. 1). The CT scan from the level just below the diaphragm showed that the aorta was of normal caliber. There were some calcifications below the level of the renals, but it was normal-caliber vessel. At the level of the bifurcation the common iliacs appeared relatively normal size. Further down in the pelvis there was a calcified mass on the left. A ventilation perfusion scan (Fig. 2) showed the mismatch on the right side, which suggested a pulmonary embolism. 36 Fig. 1 CT scan of abdomen reveals normal-caliber perirenal and infrarenal aorta (A), calcification and enlargement of iliac artery at the level of aortic and iliac bifurcation (B), and large external iliac aneurysm (C). y 37 Fig. 1 For legend see opposite page. Dr. Moore, how would you manage this patient? Dr. Moore: Clearly, with the very large iliac artery aneurysm, there is the possibility of compression of the iliac vein. That is the most likely cause of the iliofemoral venous thrombosis. This situation demonstrates the benefit of proceeding with the CT scan in a patient who has late onset or unexpected deep vein thrombosis. You expected to find cancer but you found something else that was equally causative. However, I am also concerned about the positive blood cultures. Although two out of four were S. epidev~rnidis, which certainly could have been a contaminant at the time the cultures were obtained, the infection would have to be explained as well. e Moderator: Dr. Olcott, is the location of this aneurysm important because the patient had positive blood cultures and had apparently positive blood cultures during a recent hospital admission? Dr. Olcott: It is difficult to determine because the patient had cellulitis as well. It may be a red herring. However, it should be considered. There was not too much perianeurysmal soft tissue inflammation or anything that might signify an inflammatory process. The cellulitis mav well explain it. Some additional workup is certainly necessary. 38 Fig. 2 Ventilation (A) and perfusion (B) scans reveal mismatch on right side. Ant = anterior; LPO = left posterior oblique; LLT = left lateral; LAO = left anterior oblique; RAO = right anterior oblique; RLT = right lateral; RPO = right posterior oblique; SB = single breath; E/Q = equilibrium; W/O = washout. 39 Moderator: Dr. McIntyre, how common is an isolated atherosclerotic iliac artery aneurysm? Dr. McIntyre: It is relatively uncommon to have an aneurysm of one external iliac artery with no aneurysm of the aorta or common iliac artery. It is an unusual location. However, the CT scan showed a nice rim of calcification, which indicates it could be a fairly typical atherosclerotic aneur~~sm, albeit in an unusual place. Moderator: An arteriogram, specifically digital subtraction aortography because of the patient's underlying renal insufficiency, was performed to further define the aneurysm (Fig. 3). There was some atherosclerosis affecting both renal arteries to a mild degree and some irregularity of the distal aorta and the bifurcation. The vessels appeared large and the aneurysm appeared to be confined to the external iliac artery. There was some tortuosity of the left common iliac artery and the external iliac artery aneurysm. Dr. Moore, how would you proceed? Dr. Moore: In terms of the angiographic appearance, I do not think I have ever seen an aneurysm of the external iliac artery before. That, in itself, is very unusual. The question is whether there may be a relationship between that and the positive blood cultures. However, the right side is ectatic as well. This patient may have some sort of peculiar aneurysmal distribution. On the premise that common things occur commonly, I think this is an atherosclerotic aneurysm. Whatever the etiologic basis, it is clearly compressing the venous system and it is large. It will cause trouble eventually It is already causing venous compression. I would operate on the iliac aneurysm. The interesting question is whether to do both sides or just one side. Moderator: Would you do any additional workup? Dr. Moore: Because of the septic process, I might obtain an indium white cell scan to see if there was any enhancement. However, if there was enhancement, I would not be sure how to proceed. Moderator: An indium scan could not be obtained because there was no isotope available. Dr. McIntyre, how would you manage this patient in terms of anticoagulation and the recent pulmonary embolism? Dr McIntyre: He has active thrombosis in the deep veins and should be fully anticoagulated. When was this lung scan obtained? Moderator: The ventilation perfusion scan was obtained during this admission. He was fully anticoagulated for the deep venous thrombosis. Dr. McIntyre: Was his baseline chest radiograph normal? Moderator: Yes. Dr. McIntyre: There is a high probability that this patient had a pulmonary embolism. I would prescribe a full heparinizing dose, and I would extend the partial thromboplastin (PTT) time to more than twice normal. As long as the patient is anticoagulated, there is some margin of safety. With the clot extending high up into the iliac veins, I would be concerned about another pulmonary embolism. 40 Fig. 3 Digital subtraction arteriogram of infrarenal aorta (A) and iliac arteries (B) demonstrates left external iliac aneurysm. 41 Moderator: Dr. Olcott, in planning an operation for this patient, how would you proceed with regard to anticoagulation and the pulmonary embolism? Dr. Olcott: First, when should this patient have surgery? Dr. McIntyre, touched on an interesting point. This patient probably is still going through some acute thrombotic phase and ideally that should be resolved first. On the other hand, this aneurysm may or may not be the source of the positive blood cultures and bacteremia. The most recent study showed an unusual-looking aneurysm. As Dr. Moore indicated, the patient has calcification and atherosclerosis elsewhere, but this bows out to the left and almost looks sacular on the left side, which is a little concerning. I would consider using a filter. The patient already has a low p02 value, rather borderline. There is not too much leeway if there is trouble. I would use a filter, going in from the internal jugular approach, not from below. I would do that before treating the iliac aneurysm. Moderator: What is the efficacy of isotope scans in identifying mycotic aneurysms or infected grafts ? Dr. Moore: In our institution they have been very effective in identifying graft sepsis. The only time I found a graft infection with a negative indium white blood cell scan was with S. epidermidis so that is a problem. In the absence of S. epidev~~idis, the test has been 95% specific in our experience. Dv: Mclyctyv~e: The indium 1 I 1-labeled white blood cell scan has not been a good test for diagnosing graft infection because of its high sensitivity and low specificity, especially in the early postoperative period. Given this particular scenario, I would be concerned if the aneurysm were not calcified, or if there were some perianeurysmal inflammation seen on the CT scan with no other source for sepsis. My biggest concern, however, is that the sepsis was caused by something else, for instance, an intravenous line, that may have seeded the clot that is invariably found inside these aneurysms. I do not have confidence in those particular scans in that situation. Because a mycotic aneurysm is so unusual, I would use caution in interpreting isotope scans, which have been evaluated primarily for diagnosing aortic graft infections. Moderator: Dr. Olcott, would you insert the filter preoperatively or as part of the planned operation? Dr. Olcott: It could be done either way I would probably do it preoperatively It can be done percutaneously in the cardiovascular laboratory better because a venogram of the vena cava should be obtained at the same time. Moderator: Dr. Moore, would you be concerned about operating on a patient who recently had a vena caval filter placed, particularly because you may be pressing on the vena cava? Is dislodgement a potential problem? Dr. Moore: I cannot answer that question. I have never been in that particular situation. I would be a little concerned that it could happen. On the other hand, if vena caval filters are placed properly the hooks are secure. The likelihood of knocking one free is not that great. It would not be mv first concern. I definitely agree with Dr. Olcott that a filter should be placed preoperatively. 42 Dr. Olcott: If I know where I put it and the next morning it is in the right position, I would feel much better about opening the abdomen or using the retroperitoneal approach. Dv: Mclntyv~e: In general, vena caval filter dislodgements occur because the legs in the filter are crossed and are not seated correctly. On the other hand, very few surgeons operate on patients immediately after placement of a vena caval filter, so the operative approach must be carefully planned. If a retroperitoneal approach is used on the left side, the filter probably would not be affected. I would feel fairly comfortable in having the vena caval filter in place and would not worry about dislodgement. Moderator: The concern with this patient because of the positive blood cultures and the unusual location of the aneurysm was that perhaps it might be a mycotic aneurysm, although I would agree that the appearance of this aneurysm on the CT scan is certainly more typical of an atherosclerotic process. A decision was made to operate after 7 days of full anticoagulation. Dr. Olcott, would you approach the aneurysm transabdominally or retroperitoneally because of the previous colon surgery and the left lower quadrant parastomal hernia repair? Dr. Olcott: The colostomy is in the left upper quadrant. Although the patient has had some incisions in the left lower quadrant, a retroperitoneal approach should be used. That would not be a major problem. Either approach is possible, but it would be much easier to use the left lower quadrant, retroperitoneally, because it is an external iliac artery aneurysm. Moderator: Dr. McIntyre, do you agree with using the retroperitoneal approach? a Dr. Mchttyv~e: Yes. It is important to stay out of the abdomen, primarily because of contamination from the colostomy. It should be prepared out of the field and covered with a surgical drape. Everything should be done to ensure that the area is sterile. I would make a transplant incision in the left lower quadrant and develop the retroperitoneal plane. The common iliac artery can be used as the inflow source. Based on the arteriogram, I am more comfortable that this is a rare position for an atherosclerotic aneurysm. The patient has arteriomegaly on both sides, but more so on the left. This is really a fusiform aneurysm. My concern is not the approach but rather whether to implant a prosthetic graft or do the reconstruction with autogenous tissue. Moderator: Dr. Moore, if the patient's blood cultures were positive for S. czureus or gram negative instead of positive for S. epide~~cidis, would that change your approach? Dr. Moore: My level of suspicion that sepsis was complicating an otherwise atherosclerotic aneurysm would increase considerably and I would be very concerned. Would it change the operative approach? If there was a high suspicion that it was an infected aneurysm, an extra-anatomic repair might be necessary before the aneurysm was disconnected. That would be another alternative. It depends on suspicions at that time. Out of curiosity, what was this patient's erythrocyte sedimentation rate? 43 Moderator: No sedimentation rate was obtained when the patient was admitted. Dr. Olcott: Did you repeat any cultures? Moderator: Subsequent cultures Aere negativ e. The patient had been on continuous antibiotics at the time of the surgical consultation. They were continued and the repeat cultures were negative. No further episodes of bacteremia were documented. Dr. Moore: Assuming there is a possibility but not a high probability that this is an infected aneurysm, I would have no hesitation about doing a transabdominal repair in the presence of an ostomy. We do that, not infrequently. We see many patients with colostomies and most of the time it is possible to identify a surgical approach that will not affect the ostomy. We usually cover it with a sterile plastic ostomy bag and drape it out of the way with sterile drapes. A transabdominal procedure would be my choice on this patient because I want to evaluate the right side. The patient had right-sided leg problems as well. This might be an iliac aneurysm on the left side and a year later it might be the same problem on the right side. If I explored the patient transabdominally and it was a fairly good-sized iliac aneurysm on the right side, I would probably do an aortobifemoral reconstruction and disconnect the aneurysms. Moderator: Would a retroperitoneal approach in a patient who has had a previous abdominoperineal resection lead to complications? Dr. Olcott: Not necessarily. Dr. Moore's point is a good one. Either approach can be used. Our approach to colostomies is a little different. We use a pursestring suture and close down the colostomy. The patient is evacuated, the colostomy is closed down with a pursestring suture, and a sterile drape is placed over it. I have never seen any leakage or other problem from the colostomy. I believe it is much easier to work on the external iliac artery through the retroperitoneal approach than through the abdomen. There are some advantages to a transabdominal approach and certainly the incision can be converted to that if the patient has been prepared for that possibility. However, working on the external iliac in a patient who is this ill, the less that must be done, the better. I would tailor the operation to simplify matters and address the specific issue at hand. Moderator: Once the patient is in the operating room, would you do an extra-anatomic bypass, or would you approach the aneurvsm directly? Dr. McIntyre: A great deal depends on the operative findings. It is not always possible to determine if the contents of the aneurysm are infected. If the bacteremia had totally cleared and there were no signs of inflammation in the retroperitoneum, I might be inclined to use an inline anatomic bypass with polytetrafluoroethylene (PTFE). If there was any hint whatsoever of inflammation, or if I was not firmly convinced that this was an atherosclerotic aneurysm, I would probably do the inline reconstruction with a reversed saphenous vein graft. There is a slight size discrepancy, but it is possible to complete this bypass from the common iliac to the common femoral without too many problems. 44 Moderator: Dr. Moore, some experimental evidence indicates that intra- abdominal vein grafts tend to dilate over time and cause problems when placed in the iliac or aortic position, at least in dogs. Would you agree that autogenous reconstruction would be the preferable route of reconstruction? Dr. Moore: If there was a septic process, the choices are either to do an inline autogenous repair or an extra-anatomic repair, either before or after disconnecting the aneurysm. If I used a vein, I would not be very concerned about it. The experience in humans is that only children have venous dilatation. I would rather hope there would be some venous dilatation because there would be more than a little size mismatch between the saphenous vein and the iliac artery Dr. McIntyre: Is the superficial femoral artery open in that leg? Moderator: Yes. Dr McIntyre: That is another alternative. If the vein had phlebitis or was not acceptable for use as a conduit, the superficial femoral artery could be harvested and replaced with a PTFE graft, and that could be used as an autogenous conduit in that field. I suspect it was an atherosclerotic aneurysm, it was not a major problem, and a piece of PTFE was used as a replacement. Moderator: The patient was maintained on anticoagulation up to the time of surgery An extra-anatomic bypass was performed initially because of the concern of infection using an 8 mm PTFE graft from the right to left femoral artery The left external iliac was ligated and divided so there was essentially an end-to-end anastomosis into the left groin. The wounds were closed and draped from the field. The colostomy was managed with a pursestring suture and draped out of the field with plastic drapes. A lower midline approach was used to gain access to the aneurysm. Some rather dense adhesions were taken down, but ultimately the dissection continued on to the common iliac artery just at the aortic bifurcation and proceeded toward the external iliac artery aneurysm. There was a fair amount of inflammation surrounding the aneurysm but no frank pus or necrotic tissue as is typical with mycotic aneurysms. Nevertheless, the aneurysm wall was excised along with some intraluminal thrombus and sent for pathologic diagnosis and for culture. Cultures of the aneurysmal wall were negative. Dv: McIntyre: I am sure there are different alternatives for managing this patient, but you did an excellent job with a difficult problem. Dr. Moore: What was the appearance of the external iliac on the right? Moderator: There was some generalized arteriomegaly, but no frank aneurysm. We clearly saw the compression of the iliac vein intraoperatively, as was demonstrated on the preoperative CT scan. At one point there was a transient drop in this patient's arterial saturation. He may have had an intraoperative pulmonary embolism. Following the resection of the aneurysm, we placed an inferior vena caval filter through a percutaneous transjugular approach in the operating room. Dr Moore: Did you debride the aneurvsm wall off the iliac vein? Moderator: Yes. ~ . J 45 Dr Moore: Because of a bad experience with that procedure, I would probably remove the clot and open the aneurysm. It allows significant decompression without actually trying to enter that plane between the wall and the vein. Dr. Olcott: Did you consider a retroperitoneal approach, inspecting the aneurysm, to determine whether it was mycotic rather than doing the femorofemoral bypass first? Moderator: Using a prosthetic graft in that situation would be an option. Dr. Olcott: It is hard to argue with good results. Dr Moore: However, if there is infection, it must be treated, and all the drapes must be replaced, and the patient must be reprepared to do the femorofemoral in a noninfected field. Dr. McIntyre: There was a high suspicion that this was a mycotic aneurysm, and the approach was a good one. Having not examined the patient, I would be less concerned that that would be the problem, and I would have done the extra-anatomic repair first. Moderator: Does the presence of calcification within the aneurysm rule out the possibility of a mycotic aneurysm? Dr Moore: Was it secondarily contaminated? Dr. Olcott: That may be the case with any aneurysm. This patient's condition was complicated by the presence of the positive blood cultures. There is a great deal of discussion about calcification on aneurysms. We had a patient who had a splenic artery coming off the superficial mesenteric artery and had an aneurysm right at the junction. Was it a mycotic aneurysm or an atherosclerotic aneurysm? We put a great deal of emphasis on calcification, but how long does it take for an aneurysm to become calcified? Dv: Moore: Longer than it takes for an infection to perforate an artery. Dr. McIntyre: We have previously reported that as many as 43% of patients undergoing aortic surgery have organisms cultured from the arterial wall I wonder, as Dr. Moore mentioned, whether this aneurysm could have been secondarily contaminated. Dr. Moore: I would maintain this patient on antibiotics for a good long time. Moderator: He has been maintained on antibiotics since the surgery Dr. Moore: Cellulitis of the legs may be associated with lymphedema, and if the patient has venous obstruction, he probably has lymphatic obstruction also, particularly with the previous abdominoperineal and lymph node dissection, and he may have lymphatic stasis. Moderator: Thank you very much for participating in this discussion. REFERENCE MacBeth GA, Rubin JR, McIntyre KE, et al. The relevance of arterial wall microbiology to the treatment of prosthetic graft infections: Graft infection vs. arterial infection. J Vase Surg 1:750-754, 1984.</meta-value></custom-meta></custom-meta-wrap></article-meta></front><back><ref-list>
<ref>
<citation citation-type="journal" xlink:type="simple">
<name name-style="western"><surname>MacBeth GA</surname></name>, <name name-style="western"><surname>Rubin JR</surname></name>, <name name-style="western"><surname>McIntyre KE</surname></name>, et al. <article-title>The relevance of arterial wall microbiology to the treatment of prosthetic graft infections: Graft infection vs. arterial infection</article-title>. <source>J Vase Surg</source>
<volume>1</volume>:<fpage>750</fpage>-<lpage>754</lpage>, <year>1984</year>.</citation>
</ref>
</ref-list></back></article></istex:document></istex:metadataXml><mods version="3.6"><titleInfo lang="en"><title>Management of an External Iliac Artery Aneurysm</title></titleInfo><titleInfo type="alternative" lang="en" contentType="CDATA"><title>Management of an External Iliac Artery Aneurysm</title></titleInfo><name type="personal"><namePart type="given">Eric S.</namePart><namePart type="family">Weinstein</namePart><namePart type="termsOfAddress">M.D.</namePart></name><name type="personal"><namePart type="given">Kenneth E.</namePart><namePart type="family">McIntyre</namePart><namePart type="termsOfAddress">Jr.</namePart><namePart type="termsOfAddress">M.D.</namePart></name><name type="personal"><namePart type="given">Wesley S.</namePart><namePart type="family">Moore</namePart><namePart type="termsOfAddress">M.D.</namePart></name><name type="personal"><namePart type="given">Cornelius</namePart><namePart type="family">Olcott</namePart><namePart type="termsOfAddress">IV</namePart><namePart type="termsOfAddress">M.D.</namePart></name><typeOfResource>text</typeOfResource><genre type="research-article" displayLabel="research-article"></genre><originInfo><publisher>Sage Publications</publisher><place><placeTerm type="text">Sage CA: Thousand Oaks, CA</placeTerm></place><dateIssued encoding="w3cdtf">1994-03</dateIssued><copyrightDate encoding="w3cdtf">1994</copyrightDate></originInfo><language><languageTerm type="code" authority="iso639-2b">eng</languageTerm><languageTerm type="code" authority="rfc3066">en</languageTerm></language><physicalDescription><internetMediaType>text/html</internetMediaType></physicalDescription><relatedItem type="host"><titleInfo><title>Perspectives in Vascular Surgery and Endovascular Therapy</title></titleInfo><genre type="journal">journal</genre><identifier type="ISSN">1531-0035</identifier><identifier type="eISSN">1521-5768</identifier><identifier type="PublisherID">PVS</identifier><identifier type="PublisherID-hwp">sppvs</identifier><part><date>1994</date><detail type="volume"><caption>vol.</caption><number>7</number></detail><detail type="issue"><caption>no.</caption><number>1</number></detail><extent unit="pages"><start>35</start><end>45</end></extent></part></relatedItem><identifier type="istex">DED50B80A501503DFC3F29FA2CB9F0290A6BACCE</identifier><identifier type="DOI">10.1177/153100359400700106</identifier><identifier type="ArticleID">10.1177_153100359400700106</identifier><recordInfo><recordContentSource>SAGE</recordContentSource></recordInfo></mods></metadata><serie></serie></istex></record>Pour manipuler ce document sous Unix (Dilib)
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